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Kim Y, Park HI, Chu H, Jin H, Leem J. Effectiveness and safety of acupuncture modalities for overweight and obesity treatment: a systematic review and network meta-analysis of RCTs. Front Med (Lausanne) 2024; 11:1446515. [PMID: 39234040 PMCID: PMC11372581 DOI: 10.3389/fmed.2024.1446515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 07/31/2024] [Indexed: 09/06/2024] Open
Abstract
Introduction The effectiveness and safety of acupuncture in the treatment of obesity have not been assessed. This poses a challenge for clinicians who choose to use acupuncture in the treatment of obesity, as they are unable to prioritize this approach based on outcome variables. Methods In May 2024, a literature search of five databases was conducted. Only randomized controlled trials evaluating body weight (BW), body mass index, waist circumference (WC), and adverse events in patients with a body mass index (BMI) of 25 or higher for various acupuncture modalities were included. The risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials, version 2. Pairwise meta-analysis (PMA) and Bayesian network meta-analysis (NMA) were performed using a random effects model for quantitative synthesis. Results Fourteen studies (n = 868) were included. The included studies evaluated the following acupuncture modalities: electroacupuncture (EA) (N = 6), laser acupuncture (LA) (N = 2), auricular acupuncture (AA) (N = 5), and manual acupuncture (MA) (N = 3). The PMA found that adding EA to usual care (UC), compared to UC alone, reduced BW (MD = 2.46, 95% CI = 1.12 to 3.80, I 2 = 58%, REM, N = 3, n = 157). The NMA of BW showed the following effect sizes for UC alone versus each acupuncture modality combined with UC: LA (MD = 2.09, 95% CI = 0.04 to 3.86), EA (MD = 2.04, 95% CI = 0.88 to 3.50), AA (MD = 1.69, 95% CI = -0.11 to 3.58), and MA (MD = 1.02, 95% CI = -0.82 to 2.94). The probability of each modality being the optimal treatment was evaluated using the surface under the cumulative ranking curve. EA was the most efficacious for BW and BMI, while LA was the most efficacious for WC. Discussion EA and LA can effectively complement clinical obesity management. The number of included studies was limited, and publication bias may have occurred, necessitating a cautious interpretation of the results. Furthermore, most studies lasted between six and 12 weeks. Future clinical studies of acupuncture for obesity should include longer follow-up periods. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=387788, identifier CRD42023387788.
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Affiliation(s)
- Youngjin Kim
- Wonkwang University Korean Medicine Hospital, Iksan, Republic of Korea
| | - Ha-Im Park
- Wonkwang University Gwangju Korean Medicine Hospital, Gwangju, Republic of Korea
| | - Hongmin Chu
- Mapo Hongik Korean Medicine Clinic, Seoul, Republic of Korea
| | - Hanbit Jin
- Department of Diagnostics, College of Korean Medicine, Wonkwang University, Iksan, Republic of Korea
| | - Jungtae Leem
- Department of Diagnostics, College of Korean Medicine, Wonkwang University, Iksan, Republic of Korea
- Research Center of Traditional Korean Medicine, College of Korean Medicine, Wonkwang University, Iksan, Republic of Korea
- Korean Medicine Clinical Research Institute, Wonkwang University Korean Medicine Hospital, Iksan, Republic of Korea
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Yang Z, Huang K, Yang Y, Xu Q, Guo Q, Wang X. Efficacy of traditional Chinese exercise for obesity: A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1028708. [PMID: 36936150 PMCID: PMC10014526 DOI: 10.3389/fendo.2023.1028708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 02/06/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Obesity is considered one of the biggest public health problems, especially in the background of the coronavirus disease 2019 (COVID-19) lockdown. It is urgent to find interventions to control and improve it. We performed this systematic review and meta-analysis to summarize the effect of traditional Chinese exercise on obesity. METHODS We searched PubMed, Embase, Cochrane Library, the China National Knowledge Infrastructure (CNKI), the Chinese Scientific Journal Database (VIP), the Chinese Biomedical Literature Database (CBM), and WanFang database for updated articles published from the inception of each database to June 2022. Randomized controlled trials (RCTs) on traditional Chinese exercise in weight reduction were included, and related data were extracted. The random-effects model was used to adjust for the heterogeneity of the included studies, and funnel plots were used to examine publication bias. RESULTS A total of 701 participants were included in the 10 studies. Compared with the control group, the outcome of body weight [mean difference (MD) = -6.10; 95% CI = -8.79, -3.42], body mass index (MD = -2.03; 95% CI = -2.66, -1.41), body fat mass (MD = -3.12; 95% CI = -4.49, -1.75), waist circumference (MD = -3.46; 95% CI = -4.67, -2.24), hip circumference (MD = -2.94; 95% CI = -4.75, -1.30), and waist-to-hip ratio (MD = -0.04; 95% CI = -0.06, -0.03) in the intervention group had significant differences. Egger's test and funnel plots showed that the potential publication bias of the included studies was slight (p = 0.249). CONCLUSION Traditional Chinese exercise is an effective treatment for obesity; people under the COVID-19 lockdown could do these exercises to control weight. However, a precise and comprehensive conclusion calls for RCTs on a larger scale with more rigorous designs considering the inferior methodological quality and limited retrieved articles. SYSTEMATIC REVIEW REGISTRATION www.crd.york.ac.uk/PROSPERO/, identifier CRD42021270015.
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Affiliation(s)
- Ze Yang
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Kai Huang
- Department of Orthopedics, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Yang Yang
- Department of Traditional Chinese Medicine, Neighborhood Good Doctor No. 6 Street Clinic, Hangzhou, China
| | - Qike Xu
- Department of Traditional Chinese Medicine, Neighborhood Good Doctor No. 6 Street Clinic, Hangzhou, China
| | - Qiaofeng Guo
- Department of Orthopedics, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Xiang Wang
- Department of Orthopedics, Tongde Hospital of Zhejiang Province, Hangzhou, China
- *Correspondence: Xiang Wang,
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Lima IGD, Silva JRTD, Silva AGD, Andrade ADS, Sousa LD. Electroacupuncture reduces weight, skinfold thickness and waist circumference and increases skin temperature of the abdominal region in women: a randomized controlled trial. Acupunct Med 2022; 40:425-433. [PMID: 35437025 DOI: 10.1177/09645284221077111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acupuncture, as a complementary and alternative medical treatment, has shown some promise as a therapeutic option for obesity and weight control. The aim of the current study was to investigate the effects of electroacupuncture (EA) on body weight, body mass index (BMI), skin fold thickness, waist circumference and skin temperature of the abdominal region in non-obese women with excessive abdominal subcutaneous fat. METHODS A total of 50 women with excessive abdominal subcutaneous fat (and average BMI of 22) were randomly assigned to one of two groups: an EA group (n = 25) receiving 10 EA sessions (insertion of needles connected to an electrical stimulator at a frequency of 40 Hz for 40 min) and a control group (n = 25) that received no treatment. Outcome measures evaluated included waist circumference, supra-iliac and abdominal skinfolds, body composition and superficial skin temperature (measured by cutaneous thermography) before and after treatment. RESULTS Compared with the untreated group, women in the EA group exhibited decreased supra-iliac and abdominal skin folds (p < 0.001), waist circumference (p < 0.001), percentage body fat (p = 0.001) and percentage abdominal fat (p < 0.001). In addition, the EA group showed an elevated skin temperature at the site of the treatment. However, EA did not significantly impact body weight (p = 0.01) or BMI (p = 0.2). CONCLUSION EA promoted a reduction in abdominal waist circumference, supra-iliac and abdominal skin folds, and percentage body and abdominal fat in women of normal BMI with excessive abdominal subcutaneous fat, as well as an increase in the superficial skin temperature of the abdominal region. TRIAL REGISTRATION NUMBER RBR-9tsmpp (Brazilian Registry of Clinical Trials).
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Affiliation(s)
- Isabella Gomes de Lima
- Physiotherapy Course, Institute of Motricity Sciences, Federal University of Alfenas (UNIFAL), Alfenas, Brazil
| | - Josie Resende Torres da Silva
- Physiotherapy Course, Institute of Motricity Sciences, Federal University of Alfenas (UNIFAL), Alfenas, Brazil.,Program of Biosciences Applied to Health, Federal University of Alfenas, Alfenas, Brazil
| | - Amanda Godoy da Silva
- Program of Rehabilitation Sciences, Institute of Motricity Sciences, Federal University of Alfenas, Alfenas, Brazil
| | - Alice de Sousa Andrade
- Program of Rehabilitation Sciences, Institute of Motricity Sciences, Federal University of Alfenas, Alfenas, Brazil
| | - Ligia de Sousa
- Physiotherapy Course, Institute of Motricity Sciences, Federal University of Alfenas (UNIFAL), Alfenas, Brazil.,Program of Rehabilitation Sciences, Institute of Motricity Sciences, Federal University of Alfenas, Alfenas, Brazil
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Lu PH, Chen YY, Tsai FM, Liao YL, Huang HF, Yu WH, Kuo CY. Combined Acupoints for the Treatment of Patients with Obesity: An Association Rule Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:7252213. [PMID: 35341146 PMCID: PMC8947926 DOI: 10.1155/2022/7252213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/28/2022] [Accepted: 02/15/2022] [Indexed: 11/21/2022]
Abstract
Obesity is a prevalent metabolic disease that increases the risk of other diseases, such as hypertension, diabetes, hyperlipidemia, cardiovascular disease, and certain cancers. A meta-analysis of 11 randomized sham-controlled trials indicates that acupuncture had adjuvant benefits in improving simple obesity, and previous studies have reported that acupoint combinations were more useful than single-acupoint therapy. The Apriori algorithm, a data mining-based analysis that finds potential correlations in datasets, is broadly applied in medicine and business. This study, based on the Apriori algorithm-based association rule analysis, found the association rules of acupoints among 11 randomized controlled trials (RCTs). There were 23 acupoints extracted from 11 RCTs. We used Python to calculate the association between acupoints and disease. We found the top 10 frequency acupoints were Extra12, TF4, LI4, LI11, ST25, ST36, ST44, CO4, CO18, and CO1. We investigated the 1118 association rule and found that {LI4, ST36} ≥ {ST44}, {LI4, ST44} ≥ {ST36}, and {ST36, ST44} ≥ {LI4} were the most associated rules in the data. Acupoints, including LI4, ST36, and ST44, are the core acupoint combinations in the treatment of simple obesity.
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Affiliation(s)
- Ping-Hsun Lu
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Yang Chen
- Department of Mathematics National Central University, Taoyuan, Taiwan
| | - Fu-Ming Tsai
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Yuan-Ling Liao
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Hui-Fen Huang
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Wei-Hsuan Yu
- Department of Mathematics National Central University, Taoyuan, Taiwan
| | - Chan-Yen Kuo
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
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Obesity Animal Models for Acupuncture and Related Therapy Research Studies. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:6663397. [PMID: 34630614 PMCID: PMC8497105 DOI: 10.1155/2021/6663397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 09/02/2021] [Indexed: 11/17/2022]
Abstract
Obesity and related diseases are considered as pandemic representing a worldwide threat for health. Animal models are critical to validate the effects and understand the mechanisms related to classical or innovative preventive and therapeutic strategies. It is, therefore, important to identify the best animal models for translational research, using different evaluation criteria such as the face, construct, and predictive validity. Because the pharmacological treatments and surgical interventions currently used for treating obesity often present many undesirable side effects, relatively high relapse probabilities, acupuncture, electroacupuncture (EA), and related therapies have gained more popularity and attention. Many kinds of experimental animal models have been used for obesity research studies, but in the context of acupuncture, most of the studies were performed in rodent obesity models. Though, are these obesity rodent models really the best for acupuncture or related therapies research studies? In this study, we review different obesity animal models that have been used over the past 10 years for acupuncture and EA research studies. We present their respective advantages, disadvantages, and specific constraints. With the development of research on acupuncture and EA and the increasing interest regarding these approaches, proper animal models are critical for preclinical studies aiming at developing future clinical trials in the human. The aim of the present study is to provide researchers with information and guidance related to the preclinical models that are currently available to investigate the outcomes of acupuncture and related therapies.
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Batsis JA, Apolzan JW, Bagley PJ, Blunt HB, Divan V, Gill S, Golden A, Gundamraj S, Heymsfield S, Kahan S, Kopatsis K, Port A, Parks EP, Reilly CA, Rubino D, Saunders KH, Shean R, Tabaza L, Stanley A, Tchang BG, Gundumraj S, Kidambi S. A Systematic Review of Dietary Supplements and Alternative Therapies for Weight Loss. Obesity (Silver Spring) 2021; 29:1102-1113. [PMID: 34159755 PMCID: PMC8231729 DOI: 10.1002/oby.23110] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/06/2020] [Accepted: 12/08/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Dietary supplements and alternative therapies are commercialized as a panacea for obesity/weight gain as a result of the minimal regulatory requirements in demonstrating efficacy. These products may indirectly undermine the value of guideline-driven obesity treatments. Included in this study is a systematic review of the literature of purported dietary supplements and alternative therapies for weight loss. METHODS A systematic review was conducted to evaluate the efficacy of dietary supplements and alternative therapies for weight loss in participants aged ≥18 years. Searches of Medline (PubMed), Cochrane Library, Web of Science, CINAHL, and Embase (Ovid) were conducted. Risk of bias and results were summarized qualitatively. RESULTS Of the 20,504 citations retrieved in the database search, 1,743 full-text articles were reviewed, 315 of which were randomized controlled trials evaluating the efficacy of 14 purported dietary supplements, therapies, or a combination thereof. Risk of bias and sufficiency of data varied widely. Few studies (n = 52 [16.5%]) were classified as low risk and sufficient to support efficacy. Of these, only 16 (31%) noted significant pre/post intergroup differences in weight (range: 0.3-4.93 kg). CONCLUSIONS Dietary supplements and alternative therapies for weight loss have a limited high-quality evidence base of efficacy. Practitioners and patients should be aware of the scientific evidence of claims before recommending use.
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Affiliation(s)
- John A. Batsis
- Division of Geriatric Medicine, School of Medicine, and the Department of Nutrition, The Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John W. Apolzan
- Pennington Biomedical Research Center, Louisiana State University Sysytem, Baton Rouge, Louisiana
| | | | | | | | - Sonia Gill
- University of California, Davis School of Medicine, Sacramento, California
| | | | | | - Steven Heymsfield
- Pennington Biomedical Research Center, Louisiana State University Sysytem, Baton Rouge, Louisiana
| | - Scott Kahan
- Director, National Center for Weight and Wellness, George Washington University Milken Institute School of Public Health, Washington, DC
| | | | - Ava Port
- Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore, MD
| | - Elizabeth Prout Parks
- The Children’s Hospital of Philadelphia, Division of Gastroenterology, Hepatology and Nutrition, The Healthy Weight Program, Perelman Medical Center, University of Pennsylvania
| | - Clifford A. Reilly
- The Robert Larner, M.D. College of Medicine at The University of Vermont, Burlington VT
| | - Domenica Rubino
- Washington Center for Weight Management and Research, Arlington, VA
| | - Katherine H. Saunders
- Comprehensive Weight Control Center, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine, New York, NY
| | - Ryan Shean
- Dartmouth College, Hanover, New Hampshire
| | - Luai Tabaza
- Albert Einstein Medical Center, Philadelphia, PA
| | - Abishek Stanley
- Pennington Biomedical Research Center, Louisiana State University Sysytem, Baton Rouge, Louisiana
| | - Beverly G. Tchang
- Comprehensive Weight Control Center, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine, New York, NY
| | - Shivani Gundumraj
- AT Still University School of Osteopathic Medicine in Arizona, Mesa, AZ
| | - Srividya Kidambi
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Acupuncture and Related Therapies for Obesity: A Network Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2018; 2018:9569685. [PMID: 30363899 PMCID: PMC6186334 DOI: 10.1155/2018/9569685] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/09/2018] [Indexed: 12/29/2022]
Abstract
Obesity is a worldwide public health problem. Currently, increasing evidence suggests acupuncture and related therapies are effective for obesity. This network meta-analysis (NMA) was performed to compare the effectiveness of different acupuncture and related therapies. We searched potential randomized controlled trials (RCTs) in three international databases. Thirty-four trials involving 2283 participants were included. Pairwise meta-analysis showed that acupuncture and related therapies were superior to lifestyle modification and placebo in reducing weight and body mass index (BMI). Based on decreases in body weight, results from NMA showed that acupoint catgut embedding (standard mean difference [SMD]: 1.26; 95% credible interval [95% CI], 0.46–2.06), acupuncture (SMD: 2.72; 95% CrI, 0.06–5.29), and combination of acupuncture and related theories (SMD: 3.65; 95% CrI, 0.96–6.94) were more effective than placebo. Another NMA result indicated that acupoint catgut embedding (SMD: 0.63; 95% CI, 0.25–1.11), acupuncture (SMD: 1.28; 95% CrI, 0.43–2.06), combination of acupuncture and related therapies (SMD: 1.44; 95% CrI, 0.64–2.38), and electroacupuncture (SMD: 0.60; 95% CrI, 0.03–1.22) were superior to lifestyle modification in decreasing BMI. Combination of acupuncture and related therapies was ranked the optimal method for both reducing weight and BMI. Further studies will clarify which combination of acupuncture and related therapies is better.
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Zhang RQ, Tan J, Li FY, Ma YH, Han LX, Yang XL. Acupuncture for the treatment of obesity in adults: a systematic review and meta-analysis. Postgrad Med J 2017; 93:743-751. [PMID: 28689171 DOI: 10.1136/postgradmedj-2017-134969] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/24/2017] [Accepted: 06/04/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Meta-analysis was used to assess the clinical efficacy of acupuncture treatment for simple obesity and to provide evidence-based medical data for treating obesity with acupuncture. METHODS A comprehensive search of studies on MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and Chinese databases (Wan Fang,CNKI and VIP) from 1 January 1915 through 30 November 2015 (MEDLINE search updated through 31 December 2015) was performed. We included only randomised controlled trials (RCTs) that used acupuncture and sham acupuncture to treat simple obesity. The effect of acupuncture on simple obesity was measured using body mass index (BMI), body fat mass (BFM), waist circumference (WC), hip circumference (HC), and body weight (BW). The Jadad scale was used to assess methodological quality. The random effects model was used in the pooled analysis to adjust for the heterogeneity of the included studies, and funnel plots were used to examine publication bias. The differences between treatment groups were reported as mean differences (MD). RESULTS Eleven RCTs were selected after all relevant literature from the electronic databases had been screened. There were 338 and 305 participants in the acupuncture and sham acupuncture groups, respectively. Auricular and electro acupuncture were both able to reduce BMI in obese patients (MD 0.47 kg/m2, 95% CI 0.35 to 0.58, p<0.001; MD 0.50 kg/m2, 95% CI 0.38 to 0.62, p<0.001). BFM change after acupuncture treatment compared with sham treatment was statistically significant (MD 0.66 kg, 95% CI 0.51 to 0.80, p<0.001). There were also significant differences in WC and HC between the acupuncture and sham acupuncture groups (MDwc2.02 cm, 95% CI 0.21 to 3.83, p=0.03; MDHC2.74 cm, 95% CI 1.21 to 4.27, p=0.0004). BW was not statistically significantly different between the acupuncture and sham acupuncture groups (MD 0.60 kg, 95% CI -0.20 to 1.39, p=0.14). Begg's test and funnel plots showed that the potential publication bias of the included studies was very slight (p>0.05). CONCLUSION Acupuncture for simple obesity appeared to be an effective treatment, but more studies on the safety of acupuncture used to treat simple obesity are required.
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Affiliation(s)
- Rong-Qiang Zhang
- School of Public Health, Shaanxi University of Chinese Medicine, Xianyang 712046, Shaanxi, China.,Institute of Endemic Diseases of School of Public Health, Xi'an Jiaotong University Health Science Center, Key Laboratory of Trace Elements and Endemic Diseases of the National Health and Family Planning Commission, Xi'an 710061, Shaanxi, China
| | - Jiao Tan
- Department of Public Health, Xi'an Medical University, Xi'an 710021, Shaanxi, China
| | - Feng-Ying Li
- Immunization Department of the Center for Disease Control and Prevention, Xianyang 712046, Shaanxi, China
| | - Yong-Hong Ma
- Department of Public Health, Xi'an Medical University, Xi'an 710021, Shaanxi, China
| | - Li-Xin Han
- Institute of Endemic Diseases of School of Public Health, Xi'an Jiaotong University Health Science Center, Key Laboratory of Trace Elements and Endemic Diseases of the National Health and Family Planning Commission, Xi'an 710061, Shaanxi, China
| | - Xiao-Li Yang
- Institute of Endemic Diseases of School of Public Health, Xi'an Jiaotong University Health Science Center, Key Laboratory of Trace Elements and Endemic Diseases of the National Health and Family Planning Commission, Xi'an 710061, Shaanxi, China
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